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Langman EL, Johnson KS, Dinome ML. Retained Biopsy Site Markers After Breast Lesion Surgical Resection: Associations With Residual Malignancy. AJR Am J Roentgenol 2024; 222:e2329670. [PMID: 37646391 DOI: 10.2214/ajr.23.29670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND. Biopsy site markers (BSMs) placed during image-guided core needle biopsy (CNB) are typically targeted for surgical excision, along with the breast imaging abnormality. Retained BSMs raise concern of incomplete resection of the breast abnormality. OBJECTIVE. The purpose of our study was to assess the frequency of residual malignancy in patients with retained BSMs identified on the initial mammography performed after breast lesion surgical excision. METHODS. This retrospective study included 30 patients (median age, 59 years) who underwent surgical resection between August 2015 and April 2022 of a borderline, high-risk, or malignant breast lesion after CNB and technically adequate preoperative image-guided localization, in whom the initial postoperative mammography report described a retained nonmigrated BSM. EMR data were extracted. The index pathology from CNB and initial surgical resection was classified as malignant or nonmalignant. The presence of residual malignancy after initial surgical resection required pathologic confirmation from subsequent tissue sampling; the absence of residual malignancy required 2 years of benign imaging follow-up. RESULTS. Thirteen specimen radiographs were interpreted intraoperatively by a surgeon with later radiologist interpretation, and 17 underwent real-time radiologist interpretation. Eighteen patients had malignant index pathology from the initially resected lesion. The frequency of residual malignancy on subsequent follow-up after initial surgical resection was higher in patients with malignant than nonmalignant index pathology (39% [7/18] vs 0% [0/12], respectively; p = .02). Among patients with malignant index pathology, the frequency of residual malignancy was higher in those without, than with, malignancy in the initial surgical specimen (80% [4/5] vs 23% [3/13]; p = .047). Also in these patients, the frequency of a positive interpretation of the initial postoperative mammography (BI-RADS category 4 or 6) was not significantly different between those with and without residual malignancy (57% [4/7] vs 55% [6/11]; p > .99). CONCLUSION. Patients with retained BSMs associated with malignant index lesions are at substantial risk of having residual malignancy. Initial postoperative mammography is not sufficient for excluding residual malignancy. CLINICAL IMPACT. Retained BSMs associated with index malignancy should be considered suspicious for residual malignancy. In this scenario, timely additional tissue sampling targeting the retained BSM is warranted, given the greater-than-2% chance of malignancy. Active surveillance is a reasonable management strategy in patients with retained BSMs from nonmalignant index lesions.
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Affiliation(s)
- Eun L Langman
- Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Karen S Johnson
- Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Maggie L Dinome
- Department of Surgery, Duke University School of Medicine, Durham, NC
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Jansen BAM, Bargon CA, Huibers AE, Postma EL, Young-Afat DA, Verkooijen HM, Doeksen A. Efficacy of indocyanine green fluorescence for the identification of non-palpable breast tumours: systematic review. BJS Open 2023; 7:zrad092. [PMID: 37751322 PMCID: PMC10521764 DOI: 10.1093/bjsopen/zrad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/22/2023] [Accepted: 07/20/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Accurate tumour localization is crucial for precise surgical targeting and complete tumour removal. Indocyanine green fluorescence, an increasingly used technique in oncological surgery, has shown promise in localizing non-palpable breast tumours. The aim of this systematic review was to describe the efficacy of indocyanine green fluorescence for the identification of non-palpable breast tumours. METHODS A systematic literature search was performed in PubMed, Embase, and the Cochrane Library, including studies from 2012 to 2023. Studies reporting the proportion of breast tumours identified using indocyanine green fluorescence were included. The quality of the studies and their risk of bias were appraised using the Methodological Index for Non-Randomized Studies ('MINORS') tool. The following outcomes were collected: identification rate, clear resection margins, specimen volume, operative time, re-operation rate, adverse events, and complications. RESULTS In total, 2061 articles were screened for eligibility, resulting in 11 studies, with 366 patients included: two RCTs, three non-randomized comparative studies, four single-arm studies, and two case reports. All studies achieved a 100 per cent tumour identification rate with indocyanine green fluorescence, except for one study, with an identification rate of 87 per cent (13/15). Clear resection margins were found in 88-100 per cent of all patients. Reoperation rates ranged from 0.0 to 5.4 per cent and no complications or adverse events related to indocyanine green occurred. CONCLUSION Indocyanine green fluorescence has substantial theoretical advantages compared with current routine localization methods. Although a limited number of studies were available, the current literature suggests that indocyanine green fluorescence is a useful, accurate, and safe technique for the intraoperative localization of non-palpable breast tumours, with equivalent efficacy compared with other localization techniques, potentially reducing tumour-positive margins.
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Affiliation(s)
- Britt A M Jansen
- Division of Imaging and Oncology, University Medical Centre (UMC), Utrecht University, Utrecht, The Netherlands
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, St Antonius Hospital, Utrecht, The Netherlands
| | - Claudia A Bargon
- Division of Imaging and Oncology, University Medical Centre (UMC), Utrecht University, Utrecht, The Netherlands
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, St Antonius Hospital, Utrecht, The Netherlands
| | - Anne E Huibers
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
| | - Emily L Postma
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
| | - Danny A Young-Afat
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Helena M Verkooijen
- Division of Imaging and Oncology, University Medical Centre (UMC), Utrecht University, Utrecht, The Netherlands
- Utrecht University (UU), Utrecht, The Netherlands
| | - Annemiek Doeksen
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
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Martin EA, Chauhan N, Dhevan V, George E, Laskar P, Jaggi M, Chauhan SC, Yallapu MM. Current status of biopsy markers for the breast in clinical settings. Expert Rev Med Devices 2022; 19:965-975. [PMID: 36524747 DOI: 10.1080/17434440.2022.2159807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION A breast biopsy marker is a very small object that is introduced into the breast to serve as a tissue marker. The placement of a breast marker following a biopsy or to mark an abnormality in the breast has become standard practice in the clinical setting. Breast biopsy markers offer a wide range of benefits which includes the prevention of re-biopsy of a benign tumor, differentiating multiple lesions within the breast, evaluation of the extent of a tumor, and increased precision during surgery. AREAS COVERED This review article presents a range of breast biopsy markers used in clinical practice. First, an overview of the necessity of breast markers in healthy breast management. Second, it summarizes the diversity in composition, shape, unique properties and features, and bio-absorbable carriers of breast biopsy markers. Finally, it also discusses the possible use of clinically approved breast biopsy markers in various scenarios and their implications. EXPERT OPINION This review serves as a guide in the selection of an appropriate breast marker. We believe that some of the common drawbacks associated with current breast biopsy markers can be overcome by developing novel polymer-metal and composite-based breast biopsy markers.
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Affiliation(s)
- Elian A Martin
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Neeraj Chauhan
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Vijian Dhevan
- Department of Surgery, the University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Department of Surgery, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Elias George
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Partha Laskar
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Meena Jaggi
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Subhash C Chauhan
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Murali M Yallapu
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
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Kataria K, Singh A, Jayaram J, Ranjan P, Srivastava A, Hari S, Mathur SR. Comparison of Wire-Guided Lumpectomy (WGL) Versus Hematoma-Directed Ultrasound-Guided Lumpectomy (HDUGL) in Management of Nonpalpable Breast Lesions in Achieving a Negative Resection Margin: a Randomized Trial with Superiority Hypothesis and Cost-effectiveness Analysis. Indian J Surg Oncol 2022; 13:834-841. [PMID: 36687222 PMCID: PMC9845449 DOI: 10.1007/s13193-022-01582-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 06/25/2022] [Indexed: 01/25/2023] Open
Abstract
The advances in imaging techniques and growing awareness have increased the detection of nonpalpable breast lesions, which may be neoplastic or high-risk lesions. The standard technique of localizing these nonpalpable breast lesions is wire-guided biopsy/lumpectomy. However, wire-guided excision is fraught with the complications of migration, transection, patient discomfort, pneumothorax, vasovagal episodes, and injury to the radiologist, surgeon, and pathologist. We embarked upon a randomized controlled trial to compare the cost-effectiveness and patient-reported outcome (PRO) with hematoma-directed ultrasound-guided lumpectomy (HDUGL) versus conventional wire-guided lumpectomy (WGL) for nonpalpable breast lesions. This study was a parallel design, randomized controlled trial with a superiority hypothesis. Twenty-five patients could be randomized to wire-guided lumpectomy (WGL) group (n = 13) and hematoma-directed ultrasound-guided lumpectomy (HDUGL) group (n = 12). Post-excision specimen sonography and mammography for assessing adequacy of margin were done. A margin shave was performed in cases of close or suspicious margin on ultrasonography or mammogram. Both the groups were comparable in age, tumor size, histological subtypes, and location of lesions. The median resection volume in two groups was 34.5 (26.5) ml for HDUGL vs. 41 (15) ml for WGL. Intraoperative cavity shave was required only in the WGL group (n = 3.23%) and margin positivity was also more in the WGL group (n = 2,15.38%) as compared to the HDUGL group (n = 1,8.33%) but neither differences in cavity shave nor positive margins leading to re-operations were statistically significant. The difference in cost of surgery in two groups (INR 4680 ± 560.00 for HDUGL and INR 7486 ± 616.41 for WGL) was statistically significant (P = 0.00). Resultantly, HDUGL was more cost-effective (INR 5105.45) than WGL (INR 8847.09). Patients in the HDUGL group were more satisfied according to the Likert scale of 5 but this difference in two groups was not statistically significant (P = 0.07). The hematoma-directed ultrasound-guided lumpectomy (HDUGL) is better than wire-guided lumpectomy (WGL) for nonpalpable breast lesions in terms of cost-effectiveness. Trial details: CTRI No. CTRI/2019/05/019347. Registered on 24/05/2019, Registered prospectively.
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Affiliation(s)
- Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Ankita Singh
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Jnaneshwari Jayaram
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Piyush Ranjan
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Anurag Srivastava
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Smriti Hari
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Sandeep R. Mathur
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Lee EG, Kim SK, Han JH, Lee DE, Jung SY, Lee S. Surgical outcomes of localization using indocyanine green fluorescence in breast conserving surgery: a prospective study. Sci Rep 2021; 11:9997. [PMID: 33976314 PMCID: PMC8113252 DOI: 10.1038/s41598-021-89423-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 04/23/2021] [Indexed: 11/18/2022] Open
Abstract
We investigated localization and safe resection margins for breast cancer patients undergoing breast conserving surgery (BCS) using ultrasound-guided indocyanine green fluorescence (ICG-F) marking. From April 2016 to March 2019, we prospectively enrolled 114 patients who underwent BCS using US-guided ICG-F marking and we compared these results with 300 patients who underwent BCS using US-guided skin marking from January 2012 to December 2016. Clinical features, identification rates, status of resection margins, and re-operation rates were analyzed. The ICG-F identification rate was 100% (114/114). The mean approach time for resection of the lesion ICG-F using group was about 13 min. The positive rate of frozen resection margins was 10.5% using ICG-F and 25.0% using sono-guided skin marking (p < 0.01). The rate of additional intraoperative resection was significantly lower in the ICG-F marking group compared to that in the sono-guided skin marking group (8.8% vs. 23.3%, p < 0.01). The rate of final positive resection margins was 3.5% in the ICG-F using group and 14.7% in the sono-guided skin marking group (p < 0.01). The rate of re-operation was 4.4% in the ICG-F using group and 4% in the sono-guided group (p = 0.79). At follow-up after the operation using ICG-F, no complications occurred. Using ICG-F during BCS could be a safe, sophisticated method for localization.
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Affiliation(s)
- Eun-Gyeong Lee
- Department of Surgery, Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea
| | - Seok-Ki Kim
- Department of Nuclear Medicine, National Cancer Center, Goyang, South Korea
| | - Jai Hong Han
- Department of Surgery, Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea
| | - Dong-Eun Lee
- Biostatistics Collaboration Team, Research Core Center, Research Institute of National Cancer Center, Goyang, South Korea
| | - So-Youn Jung
- Department of Surgery, Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea.
| | - Seeyoun Lee
- Department of Surgery, Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea.
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Layeequr Rahman R, Puckett Y, Habrawi Z, Crawford S. A decade of intraoperative ultrasound guided breast conservation for margin negative resection - Radioactive, and magnetic, and Infrared Oh My…. Am J Surg 2020; 220:1410-1416. [PMID: 32958157 DOI: 10.1016/j.amjsurg.2020.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/11/2020] [Accepted: 09/03/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The oncologic goal of margin-negative breast conservation requires adequate localization of tumor. Intraoperative ultrasound remains most feasible but under-utilized method to localize the tumor and assess margins. METHODS A prospectively maintained breast cancer database over a decade was queried for margin status in breast cancer patients undergoing breast conservation. Techniques of tumor localization, margin re-excision and closest margins were analyzed. Rate of conversion to mastectomy was determined. RESULTS Of the 945 breast cancer patients treated at a university-based Breast Center of Excellence between January 1, 2009 and December 31, 2018, 149(15.8%) had ductal carcinoma in situ; 712(75.3%) had invasive ductal carcinoma, and 63(6.7%) had invasive lobular carcinoma. Clinical stage distribution was: T1 = 372(39.4%); T2 = 257(27.2%); T3 = 87(9.2%). Five hundred and eighty three (61.7%) patients underwent breast conservation. The median (25th -75th centile) closest margin was 6(2.5, 10.0) mm. Thirty five (6.0%) patients underwent margin re-excision, of which 9(25%) were converted to mastectomy. Tumor localization was achieved with ultrasound in 521(89.4%) patients and with wire localization in 62(10.6%) patients. The median (25th-75th centile) closest margin with wire localization was 5.0(2.0, 8.5) mm versus 5.0 (2.0, 8.0) mm with ultrasound guidance [p = 0.6635]. The re-excision rate with wire localization was 14.5% versus 4.9% with ultrasound guidance [p = 0.0073]. The unadjusted Odds Ratio (95% CI) for margin revision in wire localized group compared with ultrasound was 3.2 (7.14, 1.42) [p = 0.0045]; multivariate adjusted OR (95%) was 4(9.09, 1.7) [p = 0.0013]. CONCLUSIONS Ultrasound guidance for localization of breast cancer remains the most effective option for margin negative breast conservation.
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Affiliation(s)
- Rakhshanda Layeequr Rahman
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Yana Puckett
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Zaina Habrawi
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Sybil Crawford
- University of Massachusetts, Medical School Division of Preventive and Behavioral Medicine, Department of Medicine, 55 Lake Avenue North, Shaw Building Room 228, Worcester, Massachusetts, 01655, USA.
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Gerrard AD, Shrotri A. Surgeon-led Intraoperative Ultrasound Localization for Nonpalpable Breast Cancers: Results of 5 Years of Practice. Clin Breast Cancer 2019; 19:e748-e752. [PMID: 31208875 DOI: 10.1016/j.clbc.2019.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/05/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND The uptake of breast screening has led to a rise in the number of nonpalpable breast cancer diagnoses. Breast conserving therapy (BCT) is the treatment of choice for early breast cancer, and this requires localization of the lesion. Commonly detection is achieved by wire-guided localization in the radiology department. This technique has complications and requires utilization of a radiologist. Intraoperative ultrasound (IOUS) has been shown to be a safe alternative, but there is little data on its use. The aim of this study is to report the use of surgeon-led IOUS over the past 5 years, assessing the ability to detect lesions and the re-excision rate for involved margins. PATIENTS AND METHODS A retrospective observational study was performed on consecutive patients undergoing IOUS-marked BCT between 2014 and 2018. The technique is described, and patients' records were reviewed to assess the histologic specimen reports and need for subsequent re-excision. RESULTS Ninety-five IOUS BCT operations were performed. Every cancer was identified by IOUS and removed. Fourteen margins were positive and required re-excision. Of these, only 2 contained residual tumor. CONCLUSION This is the first data from the United Kingdom for IOUS skin marking without wire localization. IOUS is a safe method of localization in BCT. It offers advantages both to the patient and the unit as it reduces pressure on the radiology department.
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Affiliation(s)
- Adam D Gerrard
- Breast Department, Aintree University Hospital NHS Foundation Trust, Liverpool, England
| | - Anu Shrotri
- Breast Department, Aintree University Hospital NHS Foundation Trust, Liverpool, England.
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Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision. World J Surg Oncol 2018; 16:184. [PMID: 30205823 PMCID: PMC6134720 DOI: 10.1186/s12957-018-1488-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 09/05/2018] [Indexed: 01/08/2023] Open
Abstract
Background The utilization of intraoperative ultrasound (IOUS) in breast cancer surgery is a relatively new concept in surgical oncology. Over the last few decades, the field of breast cancer surgery has been striving for a more rational approach, directing its efforts towards removing the tumor entirely yet sparing tissue and structures not infiltrated by tumor cells. Further progress in objectivity and optimization of breast cancer excision is possible if we make the tumor and surrounding tissue visible and measurable in real time, during the course of the operation; IOUS seems to be the optimal solution to this complex requirement. IOUS was introduced into clinical practice as a device for visualization of non-palpable tumors, and compared to wire-guided localization (WGL), IOUS was always at least a viable, or much better alternative, in terms of both precision in identification and resection and for patients’ and surgeons’ comfort. In recent years, intraoperative ultrasound has been used in the surgery of palpable tumors to optimize resection procedures and overcome the disadvantages of classic palpation guided surgery. Objective The aim of this review is to show the role of IOUS in contemporary breast cancer surgery and its changes over time. Methods A PubMed database comprehensive search was conducted to identify all relevant articles according to assigned key words. Conclusion Over time, the use of IOUS has been transformed from being the means of localizing non-palpable lesions to an instrument yielding a reduced number of positive resection margins, with a smaller volume of healthy breast tissue excided around tumor, by making the excision of the tumor optimal and objectively measurable.
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Merrill AY, Ochoa D, Klimberg VS, Hill EL, Preston M, Neisler K, Henry-Tillman RS. Cutting Healthcare Costs with Hematoma-Directed Ultrasound-Guided Breast Lumpectomy. Ann Surg Oncol 2018; 25:3076-3081. [DOI: 10.1245/s10434-018-6596-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Indexed: 12/28/2022]
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Vieni S, Graceffa G, Priola R, Fricano M, Latteri S, Latteri MA, Cipolla C. Ultrasound-Guided Breast-Conservative Surgery Decreases the Rate of Reoperations for Palpable Breast Cancer. Am Surg 2018. [DOI: 10.1177/000313481808400663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study is to verify whether the performance of ultrasound-guided quadrantectomy (USGQ) versus palpation-guided quadrantectomy (PGQ) can reduce the incidence of positive margins and if it can change the attitude of the surgeon. A retrospective study was conducted on 842 patients underwent quadrantectomy for breast cancer, 332 of them underwent USGQ, whereas 550 underwent PGQ. The histological type of the tumors and the margin status obtained with the histological examination were compared. The histological examination of the surgical specimen showed involvement of the margins in 24/842 patients (2.85%), 22 (2.61%) of them belonged to the PGQ group, and two to the USGQ group (P = 0.0011). The highest rate of microscopically positive margins was, statistically significant, for carcinoma in situ, when compared with patients with invasive carcinoma (0.0001). USGQ technique showed several advantages compared with PGQ. In fact, the former notes a lower positive margin rate and, consequently, a lower rate of reintervention. In addition, it may change the surgeon's attitude by causing him to remove another slice of margin to ensure more histological negativity. It should be the gold standard technique for breast-conservative surgery of palpable tumors.
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Affiliation(s)
- Salvatore Vieni
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Giuseppa Graceffa
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Roberta Priola
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Martina Fricano
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Stefania Latteri
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Mario A. Latteri
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Calogero Cipolla
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
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Volders JH, Negenborn VL, Haloua MH, Krekel NMA, Jóźwiak K, Meijer S, van den Tol PM. Breast-specific factors determine cosmetic outcome and patient satisfaction after breast-conserving therapy: Results from the randomized COBALT study. J Surg Oncol 2018; 117:1001-1008. [PMID: 29473960 DOI: 10.1002/jso.25012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/15/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES To identify breast-specific factors and the role of tumor, treatment, and patient-related items in influencing patient opinion on cosmesis and satisfaction after breast-conserving therapy (BCT). METHODS Data from the randomized COBALT study was used. At 3, 12, and 36 months, 128 patients with T1-T2 breast cancer completed a questionnaire on breast-specific factors and overall cosmetic outcome and patient satisfaction, using a 4-point Likert scale. RESULTS There was a strong positive correlation between breast-specific factors, overall cosmetic outcome,and satisfaction at all time-points. Excellent/good cosmetic outcomes and satisfaction decreased during follow-up. A shift was noted in the degree of influence of the various breast-specific factors. At 3 years, symmetry factors such as size, shape, and nipple position largely determined a patient's opinion on the final cosmesis, followed by firmness. The risk of an unacceptable outcome was associated with young age and large excision volumes. CONCLUSION A questionnaire including breast-specific questions provides important information on final cosmetic results and satisfaction after BCT. These outcomes can also be of great value as quality indicators and pre-operative counseling. The major influence of breast-specific factors on asymmetry underlines the importance of achieving an optimal excision volume at the initial procedure.
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Affiliation(s)
- José H Volders
- Department of Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Vera L Negenborn
- Department of Plastic, Reconstructive and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Max H Haloua
- Department of Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Nicole M A Krekel
- Department of Plastic, Reconstructive and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Katarzyna Jóźwiak
- Department of Epidemiology and Biostatistics, NKI-AVL, Amsterdam, The Netherlands
| | - Sybren Meijer
- Department of Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Krekel NMA, Haloua MH, Volders JH, Meijer S, van den Tol MP. Response to “The CUBE Technique: Continuous Ultrasound-Guided Breast Excision,” Published in August 2014 by Tummel et al. Amsterdam, 28th January 2015. Ann Surg Oncol 2017; 24:578. [DOI: 10.1245/s10434-017-6161-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Indexed: 11/18/2022]
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Karadeniz Cakmak G, Emre AU, Tascilar O, Bahadir B, Ozkan S. Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer. Breast 2017; 33:23-28. [DOI: 10.1016/j.breast.2017.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/11/2016] [Accepted: 02/22/2017] [Indexed: 01/14/2023] Open
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Karanlik H, Ozgur I, Sahin D, Fayda M, Onder S, Yavuz E. Intraoperative ultrasound reduces the need for re-excision in breast-conserving surgery. World J Surg Oncol 2015; 13:321. [PMID: 26596699 PMCID: PMC4657358 DOI: 10.1186/s12957-015-0731-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate ultrasound-guided surgery for palpable breast cancer by comparing the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumor-free margins, and cosmetic outcomes. METHODS This was a prospective, observational cohort study conducted from January 2009 to July 2011. Breast cancer patients, diagnosed via biopsy, were operated in guidance with either ultrasound or palpation. Patient demographics, tumor features, intraoperative findings, pathologic and cosmetic results, intraoperative-measured ultrasound margins, and pathology margins were compared. RESULTS Ultrasound (US)-guided lumpectomy was performed on 84 women and palpation-guided lumpectomy on 80 women. Patient demographics and tumor characteristics showed no differences. The rate of re-excision was 17 % for the palpation-guided surgery group, and 6 % for the US-guided group (p = 0.03). There was good correlation between the closest margins recorded by US and pathology margins (r = 0.76, p = 0.01). Volume of resection was significantly larger in the palpation-guided group despite the similar size of tumors (p = 0.048). Cosmetic outcome of surgery was equivalent between groups. CONCLUSIONS Intraoperative ultrasound guidance for excision of palpable breast cancers is feasible and gives results in terms of pathologic margins that are comparable with those achieved by standard palpation-guided excisions.
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Affiliation(s)
- Hasan Karanlik
- Surgical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey.
| | - Ilker Ozgur
- Department of General Surgery, Acibadem International Hospital, Bakirkoy, Istanbul, Turkey
| | - Dilek Sahin
- Department of Radiology, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - Merdan Fayda
- Department of Radiation Oncology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Semen Onder
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ekrem Yavuz
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Ahmed M, Rubio IT, Klaase JM, Douek M. Surgical treatment of nonpalpable primary invasive and in situ breast cancer. Nat Rev Clin Oncol 2015; 12:645-63. [PMID: 26416152 DOI: 10.1038/nrclinonc.2015.161] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Breast cancer is the most-common cancer among women worldwide, and over one-third of all cases diagnosed annually are nonpalpable at diagnosis. The increasingly widespread implementation of breast-screening programmes, combined with the use of advanced imaging modalities, such as magnetic resonance imaging (MRI), will further increase the numbers of patients diagnosed with this disease. The current standard management for nonpalpable breast cancer is localized surgical excision combined with axillary staging, using sentinel-lymph-node biopsy in the clinically and radiologically normal axilla. Wire-guided localization (WGL) during mammography is a method that was developed over 40 years ago to enable lesion localization preoperatively; this technique became the standard of care in the absence of a better alternative. Over the past 20 years, however, other technologies have been developed as alternatives to WGL in order to overcome the technical and outcome-related limitations of this technique. This Review discusses the techniques available for the surgical management of nonpalpable breast cancer; we describe their advantages and disadvantages, and highlight future directions for the development of new technologies.
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Affiliation(s)
- Muneer Ahmed
- Division of Cancer Studies, Research Oncology, King's College London, 3rd Floor, Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK
| | - Isabel T Rubio
- Breast Surgical Unit, Breast Cancer Centre, Hospital Universitario Vall d'Hebron, Paseo Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Joost M Klaase
- Department of Surgery, Medisch Spectrum Twente, Haaksbergerstraat 55, 7513 ER Enschede, Netherlands
| | - Michael Douek
- Division of Cancer Studies, Research Oncology, King's College London, 3rd Floor, Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK
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O'Kelly Priddy CM, Forte VA, Lang JE. The importance of surgical margins in breast cancer. J Surg Oncol 2015; 113:256-63. [PMID: 26394558 DOI: 10.1002/jso.24047] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 09/08/2015] [Indexed: 12/22/2022]
Abstract
Achieving negative margins with "no tumor on ink" is an appropriate goal in breast conserving therapy (BCT). Wider margins do not decrease recurrence rates, and re-excision in patients with microscopic positive margins is warranted. Several strategies exist to increase rates of negative margins, including techniques to improve tumor localization, intraoperative assessment of margins and oncoplastic techniques. Negative margins should be the goal of BCT, as this will improve both local control and long-term survival.
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Affiliation(s)
- Colleen M O'Kelly Priddy
- Department of Surgery, Section of Breast Soft Tissue Surgery, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Victoria A Forte
- Department of Medicine, Division of Medical Oncology, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Julie E Lang
- Department of Surgery, Section of Breast Soft Tissue Surgery, USC Norris Comprehensive Cancer Center, Los Angeles, California
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Ivanovic NS, Zdravkovic DD, Skuric Z, Kostic J, Colakovic N, Stojiljkovic M, Opric S, Stefanovic Radovic M, Soldatovic I, Sredic B, Granic M. Optimization of breast cancer excision by intraoperative ultrasound and marking needle - technique description and feasibility. World J Surg Oncol 2015; 13:153. [PMID: 25896818 PMCID: PMC4404261 DOI: 10.1186/s12957-015-0568-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 04/04/2015] [Indexed: 12/30/2022] Open
Abstract
Background We present a surgical technique and the preliminary results of breast cancer excision after insertion of a specially constructed marking needle into the tumor, controlled by intraoperative ultrasound. Resection margins were projected in six directions by ultrasound measurements, determined in relation to the needle, and resection was done in accordance with those measurements. The main objective was to obtain resection margins similar (equal) to those projected by intraoperative ultrasound (10 mm). Methods Detailed description of the technique is given. Thirty-two female patients undergoing breast-conserving surgery, up to 30 mm in diameter, for palpable and non-palpable invasive breast cancer, were operated on using this technique. Its feasibility was tested by analyzing the success (rate) of needle placement in the tumor, the measurements executed, and the performance of the excision. Results All stages of the technique were successfully performed to completion on all 32 patients. The procedure of needle placement and ultrasound measurement of distances took 11 min on average (between 6 and 20 min). The average distance of the tumor margin from the resection margin was 12.9 mm (2 to 30 mm, 95% confidence interval [11.9, 14.06]). There was one patient with a positive resection margin (3%). Conclusions The technique of excising palpable and non-palpable breast cancer by intraoperative ultrasound and an especially constructed marking needle is feasible and comfortable to perform. Preliminary results imply that resection volume can be rationalized, with the same or better oncological safety.
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Affiliation(s)
- Nebojsa S Ivanovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Darko D Zdravkovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Zlatko Skuric
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Jelena Kostic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Natasa Colakovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Miodrag Stojiljkovic
- Department of Pathology, UMC Bezanijska kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Svetlana Opric
- Department of Pathology, UMC Bezanijska kosa, Autoput bb, Belgrade, 11000, Serbia.
| | | | - Ivan Soldatovic
- Department of Statistics, Medical faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Biljana Sredic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Miroslav Granic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
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Optimization of breast cancer excision by intraoperative ultrasound and marking needle - technique description and feasibility. World J Surg Oncol 2015. [PMID: 25896818 DOI: 10.1186/s12957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We present a surgical technique and the preliminary results of breast cancer excision after insertion of a specially constructed marking needle into the tumor, controlled by intraoperative ultrasound. Resection margins were projected in six directions by ultrasound measurements, determined in relation to the needle, and resection was done in accordance with those measurements. The main objective was to obtain resection margins similar (equal) to those projected by intraoperative ultrasound (10 mm). METHODS Detailed description of the technique is given. Thirty-two female patients undergoing breast-conserving surgery, up to 30 mm in diameter, for palpable and non-palpable invasive breast cancer, were operated on using this technique. Its feasibility was tested by analyzing the success (rate) of needle placement in the tumor, the measurements executed, and the performance of the excision. RESULTS All stages of the technique were successfully performed to completion on all 32 patients. The procedure of needle placement and ultrasound measurement of distances took 11 min on average (between 6 and 20 min). The average distance of the tumor margin from the resection margin was 12.9 mm (2 to 30 mm, 95% confidence interval [11.9, 14.06]). There was one patient with a positive resection margin (3%). CONCLUSIONS The technique of excising palpable and non-palpable breast cancer by intraoperative ultrasound and an especially constructed marking needle is feasible and comfortable to perform. Preliminary results imply that resection volume can be rationalized, with the same or better oncological safety.
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Eggemann H, Ignatov T, Beni A, Costa SD, Ignatov A. Ultrasonography-guided breast-conserving surgery is superior to palpation-guided surgery for palpable breast cancer. Clin Breast Cancer 2013; 14:40-5. [PMID: 24169374 DOI: 10.1016/j.clbc.2013.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The aim of this study was to determine the efficacy of ultrasonography (US)-guided excision of palpable breast cancer and to compare it with the standard palpation-guided breast-conserving surgery (BCS). METHODS For this purpose, 335 women with palpable breast cancer who underwent BCS were retrospectively studied. The positive surgical margins and re-excision rates were investigated. RESULTS Of the total cohort, 137 patients were treated with palpation-guided BCS and 198 underwent US-guided tumor excision. The tumor and patient characteristics were similar in both groups. Patient age, postmenopausal status, tumor size, histological grade, intraductal tumor component, lobular histology, and palpation-guided tumor excision were associated with increased risk of positive margins. The shave margins were re-excised at the time of original operation more often by palpation-guided localization (28.5%) than by the US-guided procedure (11.1%) (P < .0001). A surgeon was able to correctly identify the "problematic" margin in 81.1% of cases via intraoperative US and in only 17.9% via palpation (P < .0001). The re-excision rate during a second operation was significantly reduced by US-guided tumorectomy (P = .004). Of 198 patients in the US-guided group, 23 (11.6%) underwent a second operation, as did 33 of 137 patients in the palpation group (24.1%). The sensitivity and specificity of US-guided excisions were 52.7% and 97.5%, respectively, whereas the sensitivity and the specificity of palpation-guided tumor excisions were 15.5% and 65.9%, respectively. CONCLUSION US-guided BCS is superior to palpation-guided excision in predicting the closest margins, obtaining clear surgical margins, and reducing re-operations.
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Affiliation(s)
- Holm Eggemann
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Tanja Ignatov
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Alexander Beni
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Serban Dan Costa
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Atanas Ignatov
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany; Department of Obstetrics and Gynecology, University Medical Center Regensburg, Regensburg, Germany.
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Pan H, Wu N, Ding H, Ding Q, Dai J, Ling L, Chen L, Zha X, Liu X, Zhou W, Wang S. Intraoperative ultrasound guidance is associated with clear lumpectomy margins for breast cancer: a systematic review and meta-analysis. PLoS One 2013; 8:e74028. [PMID: 24073200 PMCID: PMC3779206 DOI: 10.1371/journal.pone.0074028] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 07/25/2013] [Indexed: 01/27/2023] Open
Abstract
Purpose Margin status is one of the most important predictors of local recurrence after breast conserving surgery (BCS). Intraoperative ultrasound guidance (IOUS) has the potential to improve surgical accuracy for breast cancer. The purpose of the present meta-analysis was to determine the efficacy of IOUS in breast cancer surgery and to compare the margin status to that of the more traditional Guide wire localization (GWL) or palpation-guidance. Methods We searched the database of PubMed for prospective and retrospective studies about the impact of IOUS on margin status of breast cancer, and a meta-analysis was conducted. Results Of the 13 studies included, 8 were eligible for the impact of IOUS on margin status of non-palpable breast cancers, 4 were eligible for palpable breast cancers, and 1 was for both non-palpable and palpable breast cancers. The rate of negative margins of breast cancers in IOUS group was significantly higher than that in control group without IOUS (risk ratio (RR) = 1.37, 95% confidence interval (CI) = 1.18–1.59 from 7 prospective studies, odds ratio (OR) = 2.75, 95% CI = 1.66–4.55 from 4 retrospective studies). For non-palpable breast cancers, IOUS-guidance enabled a significantly higher rate of negative margins than that of GWL-guidance (RR = 1.26, 95% CI = 1.09–1.46 from 6 prospective studies; OR = 1.45, 95% CI = 0.86–2.43 from 2 retrospective studies). For palpable breast cancers, relative to control group without IOUS, the RR for IOUS associated negative margins was 2.36 (95% CI = 1.26–4.43) from 2 prospective studies, the OR was 2.71 (95% CI = 1.25–5.87) from 2 retrospective studies. Conclusion This study strongly suggests that IOUS is an accurate method for localization of non-palpable and palpable breast cancers. It is an efficient method of obtaining high proportion of negative margins and optimum resection volumes in patients undergoing BCS.
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Affiliation(s)
- Hong Pan
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
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Preoperative localization and surgical margins in conservative breast surgery. Int J Surg Oncol 2013; 2013:793819. [PMID: 23986868 PMCID: PMC3748755 DOI: 10.1155/2013/793819] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 06/06/2013] [Accepted: 07/10/2013] [Indexed: 11/29/2022] Open
Abstract
Breast-conserving surgery (BCS) is the treatment of choice for early breast cancer. The adequacy of surgical margins (SM) is a crucial issue for adjusting the volume of excision and for avoiding local recurrences, although the precise definition of an adequate margins width remains controversial. Moreover, other factors such as the biological behaviour of the tumor and subsequent proper systemic therapies may influence the local recurrence rate (LRR). However, a successful BCS requires preoperative localization techniques or margin assessment techniques. Carbon marking, wire-guided, biopsy clips, radio-guided, ultrasound-guided, frozen section analysis, imprint cytology, and cavity shave margins are commonly used, but from the literature review, no single technique proved to be better among the various ones. Thus, an association of two or more methods could result in a decrease in rates of involved margins. Each institute should adopt its most congenial techniques, based on the senologic equipe experience, skills, and technologies.
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Ahmed M, Douek M. Intra-operative ultrasound versus wire-guided localization in the surgical management of non-palpable breast cancers: systematic review and meta-analysis. Breast Cancer Res Treat 2013; 140:435-46. [PMID: 23877340 DOI: 10.1007/s10549-013-2639-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 07/09/2013] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The current standard of treatment for non-palpable breast cancers is wire-guided localization (WGL). WGL has its drawbacks and alternatives such as radio-guided surgery (RGL) and intra-operative ultrasound (IOUS) have been developed. The clinical effectiveness of all forms of RGL has been assessed against WGL in previous systematic reviews and meta-analyses. We performed the first systematic review and meta-analysis of IOUS in the management of non-palpable breast cancers. METHODS Studies were considered eligible for inclusion in this systematic review if they (1) assessed the role of surgeon-performed IOUS for the treatment of non-palpable breast cancers and ductal carcinoma in situ (DCIS) and (2) specified surgical margin excision status. Those studies, which were randomized controlled trials (RCTs) or cohort studies with comparison WGL groups were included in the meta-analysis. For those studies included in the meta-analysis, pooled odds ratios (ORs) and 95 % confidence intervals (CIs) were estimated using fixed-effects analyses and random-effects analyses in case of statistically significant heterogeneity (p < 0.05). RESULTS Eighteen studies reported data on IOUS in 1,328 patients with non-palpable breast cancer and DCIS. Nine cohort studies with control WGL groups and one RCT were included in the meta-analysis. Successful localization rates varied between 95 and 100 % in all studies and there was a statistically significant difference in the rates of involved surgical margins in favour of IOUS with pooled OR 0.52 (95 % CI 0.38-0.71). CONCLUSION Compared with WGL, IOUS reduces involved surgical margin rates. Adequately powered RCTs are required to validate these findings.
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Affiliation(s)
- M Ahmed
- Department of Research Oncology, King's College London, Guy's Hospital Campus, Great Maze Pond, London, SE1 9RT, UK.
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Thomassin-Naggara I, Jalaguier-Coudray A, Chopier J, Tardivon A, Trop I. Current opinion on clip placement after breast biopsy: a survey of practising radiologists in France and Quebec. Clin Radiol 2013; 68:e378-83. [PMID: 23522486 DOI: 10.1016/j.crad.2012.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 11/27/2012] [Accepted: 12/07/2012] [Indexed: 10/27/2022]
Abstract
AIM To investigate current practice regarding clip placement after breast biopsy. MATERIALS AND METHODS In June 2011, an online survey instrument was designed using an Internet-based survey site (www.surveymonkey.com) to assess practices and opinions of breast radiologists regarding clip placement after breast biopsy. Radiologists were asked to give personal practice data, describe their current practice regarding clip deployment under stereotactic, ultrasonographic, and magnetic resonance imaging (MRI) guidance, and describe what steps are taken to ensure quality control with regards to clip deployment. RESULTS The response rate was 29.9% in France (131 respondents) and 46.7% in Quebec (50 respondents). The great majority of respondents used breast markers in their practice (92.1% in France and 96% in Quebec). In both countries, most reported deploying a clip after percutaneous biopsy under stereotactic or MRI guidance. Regarding clip deployment under ultrasonography, 38% of Quebec radiologists systematically placed a marker after each biopsy, whereas 30% of French radiologists never placed a marker in this situation, mainly due to its cost. Finally, 56.4% of radiologists in France and 54% in Quebec considered that their practice regarding clip deployment after breast percutaneous biopsy had changed in the last 5 years. CONCLUSION There continues to be variations in the use of biopsy clips after imaging-guided biopsies, particularly with regards to sonographic techniques. These variations are likely to decrease over time, with the standardization of relatively new investigation protocols.
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Affiliation(s)
- I Thomassin-Naggara
- Department of Radiology, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, Institut Universitaire de Cancérologie, Université Pierre et Marie Curie, France.
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Krekel NMA, Haloua MH, Lopes Cardozo AMF, de Wit RH, Bosch AM, de Widt-Levert LM, Muller S, van der Veen H, Bergers E, de Lange de Klerk ESM, Meijer S, van den Tol MP. Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial. Lancet Oncol 2012; 14:48-54. [PMID: 23218662 DOI: 10.1016/s1470-2045(12)70527-2] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Breast-conserving surgery for palpable breast cancer is associated with tumour-involved margins in up to 41% of cases and excessively large excision volumes. Ultrasound-guided surgery has the potential to resolve both of these problems, thereby improving surgical accuracy for palpable breast cancer. We aimed to compare ultrasound-guided surgery with the standard for palpable breast cancer-palpation-guided surgery-with respect to margin status and extent of healthy breast tissue resection. METHODS In this randomised controlled trial, patients with palpable T1-T2 invasive breast cancer were recruited from six medical centres in the Netherlands between October, 2010, and March, 2012. Eligible participants were randomly assigned to either ultrasound-guided surgery or palpation-guided surgery in a 1:1 ratio via a computer-generated random sequence and were stratified by study centre. Patients and investigators were aware of treatment assignments. Primary outcomes were surgical margin involvement, need for additional treatment, and excess healthy tissue resection (defined with a calculated resection ratio derived from excision volume and tumour diameter). Data were analysed by intention to treat. This trial is registered at http://www.TrialRegister.nl, number NTR2579. FINDINGS 134 patients were eligible for random allocation. Two (3%) of 65 patients allocated ultrasound-guided surgery had tumour-involved margins compared with 12 (17%) of 69 who were assigned palpation-guided surgery (difference 14%, 95% CI 4-25; p=0·0093). Seven (11%) patients who received ultrasound-guided surgery and 19 (28%) of those who received palpation-guided surgery required additional treatment (17%, 3-30; p=0·015). Ultrasound-guided surgery also resulted in smaller excision volumes (38 [SD 26] vs 57 [41] cm(3); difference 19 cm(3), 95% CI 7-31; p=0·002) and a reduced calculated resection ratio (1·0 [SD 0·5] vs 1·7 [1·2]; difference 0·7, 95% CI 0·4-1·0; p=0·0001) compared with palpation-guided surgery. INTERPRETATION Compared with palpation-guided surgery, ultrasound-guided surgery can significantly lower the proportion of tumour-involved resection margins, thus reducing the need for re-excision, mastectomy, and radiotherapy boost. By achieving optimum resection volumes, ultrasound-guided surgery reduces unnecessary resection of healthy breast tissue and could contribute to improved cosmetic results and quality of life. FUNDING Dutch Pink Ribbon Foundation, Osinga-Kluis Foundation, Toshiba Medical Systems.
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Affiliation(s)
- Nicole M A Krekel
- Department of Surgical Oncology, VU University Medical Center, Amsterdam, Netherlands
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Krekel N, Haloua M, Meijer S, van den Tol M. Response to “A comparison of three methods for nonpalpable breast cancer excision”. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Barentsz MW, van Dalen T, Gobardhan PD, Bongers V, Perre CI, Pijnappel RM, van den Bosch MAAJ, Verkooijen HM. Intraoperative ultrasound guidance for excision of non-palpable invasive breast cancer: a hospital-based series and an overview of the literature. Breast Cancer Res Treat 2012; 135:209-19. [PMID: 22872521 DOI: 10.1007/s10549-012-2165-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 07/09/2012] [Indexed: 12/22/2022]
Abstract
Intraoperative ultrasound (IOUS) can be used in the operation theatre for localization of non-palpable breast cancers. In this prospective cohort study, we compared the yield of IOUS to guidewire localization (GWL). A total of 258 consecutive patients with non-palpable invasive breast cancer underwent breast conserving surgery between 1999 and 2010. GWL was performed in 138 (54 %) and IOUS in 120 (46 %) patients. Tumor dimensions, resection volume, margin status and re-excision rates were compared by means of multivariate regression analysis. The groups were similar in terms of age, histological subtype and presence of DCIS. Lesions in the IOUS group were larger (1.24 vs. 0.98 cm, P < 0.001), while microcalcifications were more common in the GWL group (19 vs. 3 %, P < 0.001). Even after stratification for tumor diameter, presence of DCIS and findings on mammography, resection volumes were similar in both groups. Tumor-free resection margins were obtained in >93 % of patients (93.5 % with GWL vs. 93.3 % with IOUS, P = 0.958) and re-excision was performed in 11 % of patients undergoing GWL and 12.5 % of patients undergoing IOUS (P = 0.684). For localization of non-palpable breast cancer, IOUS is a reliable alternative to GWL, as it achieves similar results in terms of complete tumor removal, re-excision rate and excised volume.
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Affiliation(s)
- M W Barentsz
- Department of Radiology, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Feasibility evaluation of radioimmunoguided surgery of breast cancer. INTERNATIONAL JOURNAL OF MOLECULAR IMAGING 2012; 2012:545034. [PMID: 22518303 PMCID: PMC3299315 DOI: 10.1155/2012/545034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 10/19/2011] [Accepted: 11/11/2011] [Indexed: 11/30/2022]
Abstract
Breast-conserving surgery involves completely excising the tumour while limiting the amount of normal tissue removed, which is technically challenging to achieve, especially given the limited intraoperative guidance available to the surgeon. This study evaluates the feasibility of radioimmunoguided surgery (RIGS) to guide the detection and delineation of tumours intraoperatively. The 3D point-response function of a commercial gamma-ray-detecting probe (GDP) was determined as a function of radionuclide (131I, 111In, 99mTc), energy-window threshold, and collimator length (0.0–3.0-cm). This function was used to calculate the minimum detectable tumour volumes (MDTVs) and the minimum tumour-to-background activity concentration ratio (T:B) for effective delineation of a breast tumour model. The GDP had larger MDTVs and a higher minimum required T:B for tumour delineation with 131I than with 111In or 99mTc. It was shown that for 111In there was a benefit to using a collimator length of 0.5-cm. For the model used, the minimum required T:B required for effective tumour delineation was 5.2 ± 0.4. RIGS has the potential to significantly improve the accuracy of breast-conserving surgery; however, before these benefits can be realized, novel radiopharmaceuticals need to be developed that have a higher specificity for cancerous tissue in vivo than what is currently available.
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Affiliation(s)
- Basak E Dogan
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX 77230-1439, USA.
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Krekel N, Zonderhuis B, Muller S, Bril H, van Slooten HJ, de Lange de Klerk E, van den Tol P, Meijer S. Excessive resections in breast-conserving surgery: a retrospective multicentre study. Breast J 2012; 17:602-9. [PMID: 22050281 DOI: 10.1111/j.1524-4741.2011.01198.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The main determinant of cosmetic outcomes following breast-conserving surgery (BCS) for breast cancer is the volume of resection. The importance of achieving optimal oncological control may lead to an unnecessarily large resection of breast tissue. The aim of this study is to evaluate excess resection volume in BCS for cancer by determining a calculated resection ratio (CRR). This retrospective study was conducted in four affiliated institutions and involved 726 consecutive patients with T1-T2 invasive breast cancer treated by BCS between January 2006 and 2009. The pathology reports were reviewed for tumor palpability, tumor size, surgical specimen size, and oncological margin status. The optimal resection volume (ORV) was defined as the spherical tumor volume with an added 1.0 cm margin of healthy breast tissue. The total resection volume (TRV) was defined as the ellipsoid volume of the surgical specimen. CRR was determined by dividing the TRV by the ORV. Of all tumors, 72% (525/726) were palpable, and 28% (201/726) were nonpalpable. The tumor stage was T1 in 492 patients (67.8%) and T2 in 234 patients (32.2%). The median CRR was 2.5 (0.01-42.93). Margin status was positive or focally positive in 153 patients (21.1%). Lower tumor stage was associated with a higher CRR (factor 0.61 [p < 0.0001] and a lower positive margin rate [p = 0.064]). Accordingly, the median CRR of the nonpalpable lesions was higher than that of the palpable lesions (3.1 and 2.2, respectively; p < 0.01), and the involved margin rate was lower (17.4% and 22.5%, respectively; p = 0.13). Of patients with a CRR >4.0, 10.7% still had tumor involved margins. This study clearly shows that BCS is associated with excessive resection of healthy breast tissue while clear margins are not assured. Surgical factors should be modified to improve surgical accuracy.
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Affiliation(s)
- Nicole Krekel
- Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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A plea for the biopsy marker: how, why and why not clipping after breast biopsy? Breast Cancer Res Treat 2011; 132:881-93. [DOI: 10.1007/s10549-011-1847-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 10/19/2011] [Indexed: 10/16/2022]
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Fisher CS, Mushawah FA, Cyr AE, Gao F, Margenthaler JA. Ultrasound-guided lumpectomy for palpable breast cancers. Ann Surg Oncol 2011; 18:3198-203. [PMID: 21861232 DOI: 10.1245/s10434-011-1958-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND We sought to determine the re-excision rate following lumpectomy for palpable breast cancers using intraoperative ultrasound (US). A secondary aim was to investigate the impact on surgical decision-making. METHODS We identified 73 women who underwent US-guided lumpectomy for palpable breast cancer between 2006 and 2010. A cohort of 124 women who underwent palpation-guided lumpectomy was used for a comparison group. Data included patient demographics, tumor characteristics, intraoperative findings, and pathologic outcomes. Descriptive statistics were used for data summary and compared by chi-square or t test, as appropriate. RESULTS A total of 73 women underwent US-guided lumpectomy, and 124 women underwent palpation-guided lumpectomy (median age 55 years). Patients undergoing palpation-guided lumpectomy had smaller tumors that were more likely to be HER2/neu amplified compared with patients undergoing US-guided lumpectomy (P < 0.05 for each). There were no differences between the 2 groups with respect to patient age, tumor grade, and estrogen/progesterone receptor status (P > 0.05 for each). Re-excision rates were similar in both groups [17 (23%) in the US group versus 31 (25%) in the palpation group; P > 0.05]. In the US group, 45 patients (62%) had additional shave margins taken based on US interrogation of the specimen, and 12 patients (16%) were spared a 2nd procedure based on the use of intraoperative US. CONCLUSIONS Although palpable breast cancers can be excised based on direct palpation or needle localization, we believe that US guidance provides an excellent tool to aid the breast surgeon. Only 10% of patients had a positive margin on final pathology as a result, and the overall re-excision rate was acceptable.
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Affiliation(s)
- Carla S Fisher
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Krekel NMA, Zonderhuis BM, Schreurs HWH, Cardozo AMFL, Rijna H, van der Veen H, Muller S, Poortman P, de Widt L, de Roos WK, Bosch AM, Taets van Amerongen AHM, Bergers E, van der Linden MHM, de Lange de Klerk ESM, Winters HAH, Meijer S, van den Tol PMP. Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial). BMC Surg 2011; 11:8. [PMID: 21410949 PMCID: PMC3069937 DOI: 10.1186/1471-2482-11-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 03/16/2011] [Indexed: 11/10/2022] Open
Abstract
Background Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life. Methods/design In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described. Conclusion The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life. Trial Registration Number Netherlands Trial Register (NTR): NTR2579
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Affiliation(s)
- Nicole M A Krekel
- Department of Surgical Oncology, VU University Medical Centre, Amsterdam, the Netherlands.
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Krekel NMA, Zonderhuis BM, Stockmann HBAC, Schreurs WH, van der Veen H, de Lange de Klerk ESM, Meijer S, van den Tol MP. A comparison of three methods for nonpalpable breast cancer excision. Eur J Surg Oncol 2010; 37:109-15. [PMID: 21194880 DOI: 10.1016/j.ejso.2010.12.006] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 11/17/2010] [Accepted: 12/06/2010] [Indexed: 12/14/2022] Open
Abstract
AIMS To evaluate the efficacy of three methods of breast-conserving surgery (BCS) for nonpalpable invasive breast cancer in obtaining adequate resection margins and volumes of resection. MATERIALS AND METHODS A total of 201 consecutive patients undergoing BCS for nonpalpable invasive breast cancer between January 2006 and 2009 in four affiliated institutions was retrospectively analysed. Patients with pre-operatively diagnosed primary or associated ductal carcinoma in situ (DCIS), multifocal disease, or a history of breast surgery or neo-adjuvant treatment were excluded from the study. The resections were guided by wire localisation (WL), ultrasound (US), or radio-guided occult lesion localisation (ROLL). The pathology reports were reviewed to determine oncological margin status, as well as tumour and surgical specimen sizes. The optimal resection volume (ORV), defined as the spherical tumour volume with an added 1.0-cm margin, and the total resection volume (TRV), defined as the corresponding ellipsoid, were calculated. By dividing the TRV by the ORV, a calculated resection ratio (CRR) was determined to indicate the excess tissue resection. RESULTS Of all 201 excisions, 117 (58%) were guided by WL, 52 (26%) by US, and 32 (16%) by ROLL. The rate of focally positive and positive margins for invasive carcinoma was significantly lower in the US group (N = 2 (3.7%)) compared to the WL (N = 25 (21.3%)) and ROLL (N = 8 (25%)) groups (p = 0.023). The median CRRs were 3.2 (US), 2.8 (WL) and 3.8 (ROLL) (WL versus ROLL, p < 0.05), representing a median excess tissue resection of 3.1 times the optimal resection volume. CONCLUSION US-guided BCS for nonpalpable invasive breast cancer was more accurate than WL- and ROLL-guided surgery because it optimised the surgeon's ability to obtain adequate margins. The excision volumes were large in all excision groups, especially in the ROLL group.
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Affiliation(s)
- N M A Krekel
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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Alderliesten T, Loo C, Paape A, Muller S, Rutgers E, Peeters MJV, Gilhuijs K. On the feasibility of MRI-guided navigation to demarcate breast cancer for breast-conserving surgery. Med Phys 2010; 37:2617-26. [PMID: 20632573 DOI: 10.1118/1.3429048] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the feasibility of image-guided navigation approaches to demarcate breast cancer on the basis of preacquired magnetic resonance (MR) imaging in supine patient orientation. METHODS Strategies were examined to minimize the uncertainty in the instrument-tip position, based on the hypothesis that the release of instrument pressure returns the breast tissue to its predeformed state. For this purpose, four sources of uncertainty were taken into account: (1) U(ligaments): Uncertainty in the reproducibility of the internal mammary gland geometry during repeat patient setup in supine orientation; (2) U(r_breathing): Residual uncertainty in registration of the breast after compensation for breathing motion using an external marker; (3) U(reconstruction): Uncertainty in the reconstructed location of the tip of the needle using an optical image-navigation system (phantom experiments, n = 50); and (4) U(deformation): Uncertainty in displacement of breast tumors due to needle-induced tissue deformations (patients, n = 21). A Monte Carlo study was performed to establish the 95% confidence interval (CI) of the combined uncertainties. This region of uncertainty was subsequently visualized around the reconstructed needle tip as an additional navigational aid in the preacquired MR images. Validation of the system was performed in five healthy volunteers (localization of skin markers only) and in two patients. In the patients, the navigation system was used to monitor ultrasound-guided radioactive seed localization of breast cancer. Nearest distances between the needle tip and the tumor boundary in the ultrasound images were compared to those in the concurrently reconstructed MR images. RESULTS Both U(reconstruction) and U(deformation) were normally distributed with 0.1 +/- 1.2 mm (mean +/- 1 SD) and 0.1 +/- 0.8 mm, respectively. Taking prior estimates for U(ligaments) (0.0 +/- 1.5 mm) and U(r_breathing) (-0.1 +/- 0.6 mm) into account, the combined impact resulted in 3.9 mm uncertainty in the position of the needle tip (95% CI) after release of pressure. The volunteer study showed a targeting accuracy comparable to that in the phantom experiments: 2.9 +/- 1.3 versus 2.7 +/- 1.1 mm, respectively. In the patient feasibility study, the deviations were within the 3.9 mm CI. CONCLUSIONS Image-guided navigation to demarcate breast cancer on the basis of preacquired MR images in supine orientation appears feasible if patient breathing is tracked during the navigation procedure, positional uncertainty is visualized and pressure on the localization instrument is released prior to verification of its position.
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Affiliation(s)
- Tanja Alderliesten
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), P.O. Box 90203, 1006 BE Amsterdam, The Netherlands
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Hayashi N, Tsunoda H, Abe E, Kikuchi M, Enokido K, Tsugawa K, Suzuki K, Nakamura S. Ultrasonography- and/or mammography-guided breast conserving surgery for ductal carcinoma in situ of the breast: experience with 87 lesions. Breast Cancer 2010; 19:131-7. [DOI: 10.1007/s12282-010-0218-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 07/14/2010] [Indexed: 11/25/2022]
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DeJean P, Brackstone M, Fenster A. An intraoperative 3D ultrasound system for tumor margin determination in breast cancer surgery. Med Phys 2010; 37:564-70. [PMID: 20229864 DOI: 10.1118/1.3290867] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The purpose of this study was to analyze the clinical utility of a portable three-dimensional ultrasound (3DUS) system to be used for surgical guidance of lumpectomy surgeries. In 11%-60% of lumpectomy surgeries, a second surgery is required to fully resect the tumor. Previous studies have used 3DUS as a guidance tool with the hope of more accuracy in resecting the entire tumor during the first surgery. However, they utilized larger systems, which are not easily integrated into the operating room. METHODS The portable 3DUS scanning system we developed consisted of a motorized "tilt" scanner coupled to a Terason t3000 portable ultrasound machine (Terason Ultrasound, Burlington, MA). The 3DUS system was evaluated by measuring agar "tumor" phantoms of known volumes and acquiring and segmenting images from nine patients undergoing lumpectomy. RESULTS Experiments on simulated agar tumor phantoms have shown that our device could be used to measure objects with smooth, well-defined boundaries of known volume with an error of 3%. It was possible to view and segment estimated tumor margins from the clinical images in three dimensions. Correspondence between measurements obtained in the laboratory and the operating room varied with tumor geometry and the degree of spiculation in the ultrasound image. The measured values obtained by the system did not correspond closely with those obtained using histology. However, a more accurate histological measurement using 3D histology may provide a better basis for comparison. CONCLUSIONS The results of imaging simulated agar tumor phantoms indicate the system's consistency in measuring objects of known volume and geometry. The system could be used for segmenting the approximate boundary of lumpectomy patients' breast tumors relative to inserted guide wires. The potential advantages of this system are a reduction in the number of re-excision surgeries required and a reduction in the operative time with the patient under anesthesia.
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Affiliation(s)
- Paul DeJean
- Imaging Research Laboratories, Robarts Research Institute, The University of Western Ontario, London, Ontario N6A 5K8, Canada.
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Eby PR, Calhoun KE, Kurland BF, Demartini WB, Gutierrez RL, Peacock S, Anderson BO, Byrd DR, Mann GN, Lehman CD. Preoperative and intraoperative sonographic visibility of collagen-based breast biopsy marker clips. Acad Radiol 2010; 17:340-7. [PMID: 20042350 DOI: 10.1016/j.acra.2009.10.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 10/02/2009] [Accepted: 10/12/2009] [Indexed: 11/18/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to determine the sonographic visibility of implanted collagen-based breast biopsy marker clips in the clinic and operating room. MATERIALS AND METHODS Female patients aged > or =18 years who presented for preoperative surgical evaluation within 4 weeks of ultrasound-guided breast biopsy and collagen-based marker clip placement were eligible for this pilot study. The sonographic visibility of the marker clips was rated from 1 (not visible) to 5 (clearly visible) by surgeons at the preoperative appointment, by radiologists at wire localization, and by surgeons in the operating room. Visibility was considered inadequate for values of 1 or 2 and adequate for values of 3, 4, or 5. The data were compared using Wilcoxon's signed-rank test for paired differences across physician (radiologist vs surgeon), time (preoperative visit vs day of surgery), and target (lesion vs clip). RESULTS Twenty-five patients with 26 lesions were enrolled, and 19 patients returned for all imaging procedures. The mean lesion size was 12 mm (range, 5-24 mm). Adequate marker clip visibility assessed by the surgeons decreased from 80% (20 of 25) at the preoperative appointment to 65% (11 of 17) in the operating room, but the difference was not significant (P=.27). Visibilities of the lesions and clips were similar at the preoperative appointment (P=.61), but the clips were significantly less visible on the day of operation (P=.03). CONCLUSION The sonographic visibility of collagen-based marker clips is variable and likely decreases over time but may be adequate to guide intraoperative surgical excision in many cases.
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Affiliation(s)
- Peter R Eby
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA.
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Van Esser S, Hobbelink M, Van der Ploeg I, Mali W, Van Diest P, Borel Rinkes I, Van Hillegersberg R. Radio guided occult lesion localization (ROLL) for non-palpable invasive breast cancer. J Surg Oncol 2008; 98:526-9. [DOI: 10.1002/jso.21143] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hughes JH, Mason MC, Gray RJ, McLaughlin SA, Degnim AC, Fulmer JT, Pockaj BA, Karstaedt PJ, Roarke MC. A Multi-site Validation Trial of Radioactive Seed Localization as an Alternative to Wire Localization. Breast J 2008; 14:153-7. [DOI: 10.1111/j.1524-4741.2007.00546.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Potter S, Govindarajulu S, Cawthorn SJ, Sahu AK. Accuracy of sonographic localisation and specimen ultrasound performed by surgeons in impalpable screen-detected breast lesions. Breast 2007; 16:425-8. [PMID: 17374484 DOI: 10.1016/j.breast.2007.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 01/30/2007] [Accepted: 02/01/2007] [Indexed: 11/23/2022] Open
Abstract
The National Breast Screening Programme had dramatically impacted surgical practice. Up to 50% of all newly diagnosed cancers are now impalpable creating increased demand for image-guided localisation. Wire-guided localisation (WGL) is the current gold standard, but USS-guided localisation by radiologists is a well-documented and effective technique. Increasing numbers of surgeons are proficient in using ultrasound and may be as accurate as radiologists in localising lesions intra-operatively. Of 68 patients with screen-detected impalpable lesions referred to one surgeon in our unit between January 2005 and February 2006, 32 had mass lesions, which were well seen on ultrasound and underwent intra-operative USS-guided localisation performed by a surgeon. All lesions were correctly identified and 87.5% (n=28) were fully excised. Those lesions not fully excised were lobular cancers. Intra-operative sonographic localisation performed by surgeons is an accurate and effective technique. It may produce less patient anxiety and discomfort than WGL and allow more effective and efficient use of resources and theatre time.
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Affiliation(s)
- S Potter
- Frenchay Hospital, Beckspool Road, Frenchay, Bristol, BS16 1JE, England, UK.
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Haid A, Knauer M, Dunzinger S, Jasarevic Z, Köberle-Wührer R, Schuster A, Toeppker M, Haid B, Wenzl E, Offner F. Intra-operative sonography: a valuable aid during breast-conserving surgery for occult breast cancer. Ann Surg Oncol 2007; 14:3090-101. [PMID: 17593330 DOI: 10.1245/s10434-007-9490-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Accepted: 05/24/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND Breast cancer is increasingly detected during an early non-palpable stage. Together with pre-operative marking of the mass, intra-operative imaging provides invaluable clues. This study was designed to evaluate the usefulness of intra-operative sonography in the hands of the surgeon. METHODS Between July 2001 and October 2006, 567 patients underwent treatment for operable breast cancer at the landeskrankenhaus (LHK) Feldkirch. Three hundred and sixty lesions were not palpable. Two hundred and ninety-nine patients with poorly definable or non-definable lesions well seen by ultrasound imaging underwent intra-operative sonography (group 1), while 61 patients with non-palpable lesions only seen on mammography (group 2) were subjected to pre-operative needle localization. The study was non-randomized with prospective data acquisition RESULTS All lesions were identified by both sonography and pre-operative needle localization. In the ultrasound group (group 1) 81% of the lesions were successfully removed by primary intention without metachronous secondary surgery versus 62% in group 2 (p < 0.00228). Eighty-eight percent of the lesions in group 1 were eligible for breast-conserving surgery versus 75% in group 2. The mean clear margin in group 1 was substantially smaller (4.8 mm) than in group 2 (7.2 mm) (p < 0.0001). CONCLUSION Intra-operative sonography proved to be a reliable and helpful tool in the hands of the surgeon, not only for tumor localization, but also for orientation during tumor excision. It simplifies organizational work and spares the patient the discomfort of pre-operative needle localization.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnostic imaging
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/diagnostic imaging
- Carcinoma, Lobular/surgery
- Cell Differentiation
- Female
- Humans
- Intraoperative Care
- Male
- Mammography
- Mastectomy, Segmental
- Medical Records
- Middle Aged
- Palpation
- Predictive Value of Tests
- Prospective Studies
- Risk Assessment
- Sensitivity and Specificity
- Ultrasonography
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Affiliation(s)
- Anton Haid
- Department of General and Thoracic Surgery, Landeskrankenhaus Feldkirch, Teaching Hospital of Innsbruck University, Carinagasse 47-49, 6800, Feldkirch, Austria.
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Layeequr Rahman R, Crawford S, Larkin A, Quinlan R. Superiority of Sonographic Hematoma Guided Resection of Mammogram Only Visible Breast Cancer: Wire Localization Should be an Exception—Not the Rule. Ann Surg Oncol 2007; 14:2228-32. [PMID: 17514405 DOI: 10.1245/s10434-007-9422-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 03/16/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND The goal of breast conservation in cancer treatment is to obtain adequate margins with minimum tissue loss to achieve acceptable oncologic and cosmetic outcome. The standard for resection of breast cancers visible only on mammogram is wire localization (WL), which has a high rate of positive margins. We hypothesized that sonographic hematoma guided (SHG) resection achieves better margin clearance while minimizing volume of resection by more accurate lesion localization. METHODS This retrospective study was conducted at the University Comprehensive Breast Center. Consecutive patients over the span of one year, undergoing breast conservation for stereotactic biopsy proven cancers that were not visualized on ultrasound were studied. SHG and WL technique were compared for age, mammographic abnormality, and tumor characteristics. Outcome variables included closest margin of resection, volume of resection, resection index (resection volume/tumor volume), and rate of margin revision. RESULTS Forty-five patients had SHG, while 51 had WL lumpectomy. The SHG and WL groups were similar in age, mammographic abnormality, tumor type, and stage. Median (25th-75th centile) tumor size was larger in SHG group vs WL group [1.2 (1.1-1.3) vs 0.8 (0.4-1.4) cm; P = .009]. Median (25th-75th centile) closest margin in SHG vs WL group was 5.0 (5.0-8.0) vs 4.0 (1.0-10) mm [P = .0041]. Median (25th-75th centile) resection volume in SHG vs WL group was 85.0 (60.0-128.0) vs 142.2 (54.4-229.0) cm(3) [P = .0127]. Median (25th-75th centile) resection index in SHG vs WL group was 77.3 (59.3-285.7) vs 337.1 (88.9-3982.2) [P = .0004]. Margin was revised in 2 (4.4%) SHG vs 8 (15.7%) WL patients [P = .0978]. CONCLUSION Sonographic hematoma guided lumpectomy is superior to wire localization in obtaining adequate margins with minimal volume of resection.
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Kaufman CS, Jacobson L, Bachman BA, Kaufman LB, Mahon C, Gambrell LJ, Seymour R, Briscoe J, Aulisio K, Cunningham A, Opstad F, Schnell N, Robertson J, Oliver L. Intraoperative Digital Specimen Mammography: Rapid, Accurate Results Expedite Surgery. Ann Surg Oncol 2007; 14:1478-85. [PMID: 17235716 DOI: 10.1245/s10434-006-9126-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 05/26/2006] [Accepted: 06/19/2006] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Specimen mammography during image guided breast surgery is a daily occurrence. The process of specimen travel, imaging and reporting may take 20-30 minutes. An intraoperative method to obtain digital specimen mammograms may expedite the process. We compared intraoperative digital specimen mammography (IDSM) as well as standard specimen mammography (SSM) on 121 consecutive image guided lumpectomies. METHODS Each lumpectomy specimen had IDSM obtained followed by travel to radiology for SSM. Surgical decisions were based on all imaging obtained. Data included 1) the ability of each imaging method to identify the target lesion, 2) degree of concordance of surgical interpretation of IDSM compared to radiologist interpretation of SSM, 3) the time required from lumpectomy to surgical review of images from each method, and 4) potential operative time savings. RESULTS Intraoperative digital specimen mammography (IDSM) was equally as accurate as standard x-ray film specimen mammography. There was no significant difference between 1) the frequency of identification of the target lesion by surgeon or radiologist, 2) lack of identification of any lesion, or 3) frequency of involved margins using imaging criteria. However, there was a marked difference in 1) the time needed to obtain images ready to read, 2) the ability to re-excise tissue promptly, and 3) the overall operating room time with an average decrease of 19 minutes. CONCLUSIONS Intraoperative digital specimen mammography (IDSM) was equally accurate as SSM obtained in this study. Use of this new technology allows surgeons to quickly view specimen images which translate into shorter more efficient operations.
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Affiliation(s)
- Cary S Kaufman
- Department of Surgery, University of Washington, Washington, USA.
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Tafra L, Fine R, Whitworth P, Berry M, Woods J, Ekbom G, Gass J, Beitsch P, Dodge D, Han L, Potruch T, Francescatti D, Oetting L, Smith JS, Snider H, Kleban D, Chagpar A, Akbari S. Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumors. Am J Surg 2006; 192:462-70. [PMID: 16978950 DOI: 10.1016/j.amjsurg.2006.06.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Revised: 06/15/2006] [Accepted: 06/15/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study compared the surgical results of 2 localization methods-cryo-assisted localization (CAL) and needle-wire localization (NWL)-in patients undergoing breast lumpectomy for breast cancer. METHODS A total of 310 patients were treated in an institutional review board-approved study with 18 surgeons at 17 sites. Patients were randomized 2:1 to undergo either intraoperative CAL or NWL. A cryoprobe was inserted under ultrasound guidance in the operating room and an ice ball created an 8- to 10-mm margin around the lesion. The palpable ice ball then was dissected. NWL was placed according to institutional practice and resection was performed in a standard fashion. Surgical margins, complications, re-excisions, tissue volume, procedure times, ease of localization, specimen quality, and patient satisfaction were evaluated. Positive margins were defined as any type of disease present 1 mm or less from any specimen edge. RESULTS Positive margin status did not differ between the 2 groups (28% vs. 31%). The volume of tissue removed was significantly less in the CAL group (49 vs. 66 mL, P = .002). Re-excisions were similar in both groups. CAL was superior in ease of lumpectomy, quality of specimen, acute surgical cosmesis, short-term cosmesis, patient satisfaction, and overall procedure time for the patient. CAL had a lower invasive positive margin rate (11% vs. 20%, P = .039) but a higher observed ductal carcinoma in situ-positive margin rate (30% vs. 18%, approaching statistical significance, P = .052). CONCLUSIONS CAL is a preferred alternative to standard wire localization because it provides a palpable template, removes less tissue and improves cosmesis, decreases overall procedure time, and is more convenient for the patient and surgeon.
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Affiliation(s)
- Lorraine Tafra
- Anne Arundel Medical Center, 2002 Medical Pkwy., Suite 120, Annapolis, MD 21401, USA.
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Li Y, Holloway CMB, Purcell CM, Wang J, Plewes DB. An MRI/US/x-ray compatible breast localization marker: in vivo evaluation. Acad Radiol 2005; 12:1557-66. [PMID: 16321745 DOI: 10.1016/j.acra.2005.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 07/18/2005] [Accepted: 08/03/2005] [Indexed: 11/23/2022]
Abstract
RATIONALE AND OBJECTIVES An in vivo evaluation of a new trimodality breast localization marker was performed with magnetic resonance imaging (MRI), ultrasound (US), x-ray, and histopathology. The evaluation of the marker in animal tests should help define its utility for surgical biopsy localization in humans. MATERIALS AND METHODS Five rabbits were used and sacrificed at 2 days, 1 week, 2 weeks, 4 weeks, and 7 weeks after marker implantation. The marker placement and tissue biopsies were performed under US guidance. MRI, US, and x-ray imaging were performed to monitor the contrast of the marker, track marker migration. The biologic compatibility of the marker was demonstrated by histopathologic analysis. RESULTS The contrast of the marker was clear and stable on each imaging modality over the 7-week study period. Acute inflammation was visible by 2 days after marker injection, with evidence of granulation tissue and angiogenesis at 2 weeks after implantation. A modest degree of chronic inflammation and angiogenesis remained evident at 4 weeks after procedure, and fibrosis persisted 7 weeks after procedure with no further tissue changes. These results suggest that the new marker is biocompatible and can remain interstitial for up to 7 weeks. Furthermore, very little marker migration was observed. On removal, the marker was found to be mechanically stable. CONCLUSION This in vivo animal study demonstrates that the new marker may be appropriate for in vivo human testing and as an alternative to traditional wire localization currently used for breast surgery.
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Affiliation(s)
- Yangmei Li
- Imaging Research, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ontario M4N 3M5, Canada
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Nurko J, Mancino AT, Whitacre E, Edwards MJ. Surgical benefits conveyed by biopsy site marking system using ultrasound localization. Am J Surg 2005; 190:618-22. [PMID: 16164935 DOI: 10.1016/j.amjsurg.2005.06.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Revised: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND With vacuum-assisted biopsy technology all, or most, of a breast lesion may be removed during the initial biopsy; in such cases a metallic marker is often inserted at the site of the biopsy for future localization. The aim of this study was to evaluate the efficacy and impact of the Gel Mark Ultra biopsy site marking system (SenoRx, Aliso Viejo, CA) on the practice of needle localization breast biopsy. METHODS We retrospectively analyzed the experience of 45 general surgeons across the United States in a variety of practice settings using the Gel Mark Ultra clip. Imaging-guided biopsy technique, localization quality, surgeon confidence, and margin status were assessed and compared against the broad data reported in the literature. RESULTS A total of 432 records of patients who underwent imaging-guided breast biopsy with placement of Gel Mark Ultra clip were reviewed. Of these, 63 (15%) patients required definitive surgical intervention, for which 41 cases were localized with ultrasound and assessed for margin clearance. Clear margins were achieved in 37 (90%) of the 41 cases. These results are statistically superior (P < .01) to positive margins rates reported in the literature. CONCLUSIONS The Gel Mark Ultra biopsy site marking system is a new localization device that provides a safe and effective alternative to traditional localization methods with a significant reduction in the percentage of positive margins, as well as advantages in terms of surgical approach, time, and patient comfort.
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Affiliation(s)
- Jacobo Nurko
- The University of Arkansas for Medical Sciences, 4301 W. Markham, Slot 520, Little Rock, AR 72205, USA.
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Bennett IC, Greenslade J, Chiam H. Intraoperative ultrasound-guided excision of nonpalpable breast lesions. World J Surg 2005; 29:369-74. [PMID: 15706446 DOI: 10.1007/s00268-004-7554-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The methods commonly used to guide surgical excision of impalpable breast lesions include preoperative placement of hookwires, carbon injections, and, more recently, radioisotope injections. However, all of these techniques have disadvantages, not the least of which is subjecting the patient to an additional stressful and often traumatic procedure preoperatively. The use of intraoperative ultrasound to guide the excision of sonographically visible impalpable lesions is a new technique that avoids the need for a preoperative localization procedure. This report describes one of the author's (I.B.) personal series of ultrasound-guided breast excisions, collating data collected prospectively, and reviews the efficacy of this technique. Data in relation to 115 ultrasound guided breast excisions performed in 103 patients were reviewed. The technique of using a high-frequency real-time ultrasound probe intraoperatively to localize and guide excision of breast abnormalities is described. There were no failed excisions, as confirmed by specimen sonography, pathology findings, and/or follow-up ultrasound. Breast malignancies comprised 42% of all excised lesions, and of these, adequate margins of excision were achieved at the first operation in 93% of cases. Direct ultrasound localization of the lesion at the time of surgery allowed optimal placement of the incision and eliminated delays in operating time because specimens did not have to be sent to the Radiology Department for confirmation of excision. Intraoperative ultrasound-guided excision is a safe and efficient technique in the management of impalpable, sonographically visible breast lesions, and early reports in the world literature support the findings of this series, which show it to have significant advantages over other current methods, particularly with respect to a reduction in patient anxiety and improved surgical resection margins.
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Affiliation(s)
- I C Bennett
- Department of, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, and Wesley Hospital, Brisbane, Australia
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Abstract
Ultrasound is becoming an indispensable tool for the surgeon in the diagnosis and treatment of a variety of breast problems. Hands-on ultrasound education for surgeons and the ongoing improvements in imaging technology have made surgeon-performed breast ultrasound an effective method of identifying and diagnosing breast lesions and have increased the surgeon's ability to perform ultrasound-guided interventional procedures. This article reviews the current state of surgeon-performed breast ultrasound.
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Gallegos Hernandez JF, Tanis PJ, Deurloo EE, Nieweg OE, Th Rutgers EJ, Kroon BBR, Valdés Olmos RA. Radio-guided surgery improves outcome of therapeutic excision in non-palpable invasive breast cancer. Nucl Med Commun 2004; 25:227-32. [PMID: 15094439 DOI: 10.1097/00006231-200403000-00003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intratumoral injection of a radiocolloid for lymphatic mapping enables the therapeutic excision of clinically occult breast cancer with the aid of a gamma-ray detection probe. The aim of this study was to determine the success rate of radio-guided tumour excision in addition to a guide wire and to identify factors predicting clear margins. Sixty-five consecutive patients underwent radio-guided tumour excision after intratumoral injection of 99mTc-nanocolloid guided by ultrasound or stereotaxis. A localization wire was inserted after scintigraphy had been performed (group 1). The results were compared with retrospective data from 67 consecutive patients who underwent therapeutic wire-directed excision alone (group 2). Factors predicting clear margins (> or = 1 mm) were determined in a logistic regression model. Adequate margins were obtained in 83% of group 1 and in 64% of group 2 (P = 0.014). The invasive component was incompletely excised in two patients in group 1 and in 14 patients in group 2. Further surgery was performed in four patients in group 1 and in 14 patients in group 2. Factors predictive of clear margins were decreasing pathological tumour diameter (P = 0.035), increasing weight of the specimen (P = 0.046), absence of microcalcifications (P = 0.004) and absence of carcinoma in situ component (P = 0.024). Radio-guided excision was an independent predictor of complete excision of the invasive component (P = 0.012). The application of radio-guided surgery combined with wire localization seems to improve the outcome of therapeutic excision of non-palpable invasive breast cancer compared with wire-directed excision alone.
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Chen SC, Yang HR, Hwang TL, Chen MF, Cheung YC, Hsueh S. Intraoperative ultrasonographically guided excisional biopsy or vacuum-assisted core needle biopsy for nonpalpable breast lesions. Ann Surg 2003; 238:738-42. [PMID: 14578737 PMCID: PMC1356153 DOI: 10.1097/01.sla.0000094439.93918.31] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare duration and rates of underestimation and complete excision for nonpalpable breast lesions using either intraoperative ultrasonographically guided excisioned biopsy (IUGE) or directional vacuum-assisted biopsy (DVAB). SUMMARY BACKGROUND DATA Percutaneous ultrasonography-guided core needle biopsy is preferable to stereotactic biopsy for treatment of nonpalpable breast lesions; however, underestimation and false-negative results can occur, and rebiopsy may be required. To date, however, there has been no comparison of these two procedures in terms of diagnostic accuracy and duration. METHODS For 4 consecutive years, IUGE was performed for 104 nonpalpable breast lesions and DVAB for 128 lesions at Chang Gung Memorial Hospital. Of the DVAB cases, the handheld mammotome was used for 53 procedures, with all lesions removed as completely as possible. The duration of the two procedures was calculated from initial skin incision until completion of wound closure. Most of the patients with benign pathology underwent ultrasonographic examination at 3 months after surgery, with a follow-up examination at 1 year. Surgery was performed subsequently for all of the malignancy cases. RESULTS The average ages and mean tumor sizes for patients undergoing IUGE or DVAB were 46 and 47 years and 1.1 and 1.0 cm, respectively. The average IUGE and DVAB surgery durations for 88 benign tumors and 117 benign lesions were 44.3 and 21.5 minutes, respectively (P < 0.001), and 43.5 and 20.6 minutes for the malignant tumors (n = 16 and n = 11), respectively (P = 0.036). The IUGE and DVAB surgery durations for tumors <1 cm in diameter were 43.5 and 20.6 minutes, respectively, and 44.2 and 23.6 minutes for tumors over that size (P < 0.001). An older-model mammotome was used for 75 patients, with an average duration of 24 minutes in comparison to 18 minutes for the handheld variant (P < 0.001). No false-negative results were noted and, except in the case of the malignant tumors, there was no need for reexcisional biopsy. Further, there were no underestimates of the disease for the 4 cases of atypical ductal hyperplasia and the 12 of noninvasive carcinoma. No further ultrasonographic evidence of tumors was noted for 95% of the benign pathologies, with no residual abnormality detected for 13 of the 27 malignant tumors after IUGE or DVAB. CONCLUSIONS For treatment of nonpalpable breast lesions, both IUGE and DVAB eliminate false-negative results, underestimates, and the requirement for reexcisional biopsies. In comparison to IUGE, DVAB is more convenient and time efficient for excisional biopsy of nonpalpable breast lesions.
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Affiliation(s)
- Shin-Cheh Chen
- Department of Surgery, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, Taiwan.
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